Assessment

Nursing Diagnosis

Planning

Intervention

Evaluation

S: Nahihirapan na siyang huminga, halos yung oxygen nalang nga yung tumutulong sa kaniya. O: -with rapid shallow breathing noted -(+) use of accessory muscle noted -(+) secretions noted on mouth characterized by colored white purulent discharges approximately 34cc -(+) crackles sound heard on both lung fields upon auscultation -with NGT inserted draining to dark green to black purulent discharges approximately 311cc

Ineffective Breathing Pattern r/t Tracheobronchial obstruction Definition: Inspiration and expiration that does not provide adequate ventilation. Etiology: Presence of secretion in the bronchi will result into blockage of air that will enter the body thus producing insufficient air. Background Theory: The Henderson theory of nursing encompasses a definition of

STG: AT the end of 8 hours nursing intervention, SO will be able to demonstrate measures that will help the client to

1. V/S monitored and recorded. For baseline data and to note alterations.

Was partially met AEB proper ambubagging done by SO; turning to side every 2 hours.

2. Placed in supine position and assisted in turning to Left side every 2 LTG: hours. At the end of 3 To facilitate good days nursing lung excursion and intervention, will be chest expansion. able to maintain patent airway. 3. Instructed SO to do back clapping. To loosen secretions 4. Assisted SO in proper ambubagging; O2 regulated @ desired rate. To provide adequate oxygenation needed.

-with O2 inhalation connected to ambubag regulated @ 6LPM -with hemoglobin count of 109 g/l -with D5LR 1L x 30gtts/min with SD of D5w 500 cc +1amp aminocids regulated at 30 gtts/min V/S: T=39.4 P=140 RR=36bpm BP=130/80 mmhg

nursing, a description of the function of a nurse, and the enumeration of the 14 components that make up basic nursing care. In her 14 components of basic needs, the second most important was the oxygenation or breathing.